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Population Based: Evaluation of Femoroacetabular Impingement

Year 2024, Volume: 6 Issue: 2, 126 - 135, 30.06.2024
https://doi.org/10.52827/hititmedj.1339302

Abstract

Objective: Femoroacetabular impingement is a dysfunction of the hip joint with the potential to cause early hip osteoarthritis. The aim of this study was to examine the Alpha Angle and Femoral Neck-Head Offset measurements of patients who underwent pelvic Computed Tomography examination for any indication with radiologists.
Material and Method: The results of 1,782 right and left hip joints of 891 individuals aged 18-45 years who
underwent pelvic computed tomography examination (with or without contrast) for various reasons were evaluated retrospectively. Alpha Angle and Femoral Neck-Head Offset measurements were performed on computed tomography sections. In this study, an Alpha Angle of 55° or more and a Femoral Neck-Head Offset distance of less than 8 mm were considered abnormal.
Results: A total of 891 individuals, 758 (85.1%) males and 133 (14.9%) females, were included in this study. The mean age of the individuals was 24.65 ± 6.01 years. The mean right Alpha Angle was 45.42 ± 4.4 (min 38.00, max 62.00), the mean left Alpha Angle was 46.65 ± 5.1 (min 38.00, max 72.10), the mean right Femoral Neck-Head Offset was 10.21 ± 0.02 (min 6.2, max 11.4), and the mean left Femoral Neck-Head Offset was 10.57 ± 0.01 (min 5.6, max 12.0). The total number of individuals with Alpha Angle ≥ 55° in both hip joints was 37, 33 of whom were male and 4 were female. There were no individuals with Femoral Neck-Head Offset < 8 mm in both hip joints.
Conclusion: Imaging features known to be associated with femoroacetabular impingement are seen in
asymptomatic adult hip joints, particularly in males. If anthropometric measurements are outside normal limits in asymptomatic young male and female individuals, clinical correlation of the findings of these individuals should be recommended.

Project Number

Yok

References

  • Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage. J Bone Joint Surg Br. 2005;87-B(7):1012-1018.
  • Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):112-120.
  • Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris- Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644.
  • Fortier LM, Popovsky D, Durci MM, Norwood H, Sherman WF, Kaye AD. An Updated Review of Femoroacetabular Impingement Syndrome. Orthopedic reviews. 2022;14(3):37513.
  • Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008;466(2):264-272.
  • Wagner S, Hofstetter W, Chiquet M, et al. Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement. Osteoarthritis Cartilage. 2003;11(7):508-518.
  • Schmaranzer F, Kheterpal AB, Bredella MA. Best Practices: Hip Femoroacetabular Impingement. AJR Am J Roentgenol. 2021;216(3):585-598.
  • Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90 Suppl 4(Suppl 4):47-66.
  • Shaw C. Femoroacetabular Impingement Syndrome: A Cause of Hip Pain in Adolescents and Young Adults [published correction appears in Mo Med. 2017 Sep-Oct;114(5):352]. Mo Med. 2017;114(4):299-302.
  • Trigg SD, Schroeder JD, Hulsopple C. Femoroacetabular Impingement Syndrome. Curr Sports Med Rep. 2020;19(9):360- 366.
  • Kim J, Choi JA, Lee E, Lee KR. Prevalence of Imaging Features on CT Thought to Be Associated With Femoroacetabular Impingement: A Retrospective Analysis of 473 Asymptomatic Adult Hip Joints. AJR Am J Roentgenol. 2015;205(1): W100-W105.
  • Fernandez M, Wall P, O’Donnell J, Griffin D. Hip pain in young adults. Aust Fam Physician. 2014;43(4):205-209.
  • Murphy NJ, Eyles JP, Hunter DJ. Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in therapy. 2016;33(11):1921-1946.
  • Ahn T, Kim CH, Kim TH, Chang JS, Jeong MY, Aditya K, et al. What is the Prevalence of Radiographic Hip Findings Associated With Femoroacetabular Impingement in Asymptomatic Asian Volunteers? Clinical orthopaedics and related research. 2016;474(12):2655-2661.
  • Seijas, R., Pérez-Bellmunt, A., Barastegui, D. et al. Correction to: The natural history of alpha angle in the last seventeen centuries. Arch Orthop Trauma Surg 142, 2827 (2022).
  • Nötzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
  • Sutter R, Dietrich TJ, Zingg PO, Pfirrmann CW. How useful is the alpha angle for discriminating between symptomatic patients with cam-type femoroacetabular impingement and asymptomatic volunteers?. Radiology. 2012;264(2):514-521
  • Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
  • Wylie JD, Peters CL, Aoki SK. Natural History of Structural Hip Abnormalities and the Potential for Hip Preservation. The Journal of the American Academy of Orthopaedic Surgeons. 2018;26(15):515-525.
  • Amanatullah DF, Antkowiak T, Pillay K, Patel J, Refaat M, Toupadakis CA, et al. Femoroacetabular impingement: current concepts in diagnosis and treatment. Orthopedics. 2015;38(3):185-199.
  • Carton PF, Filan DJ. The clinical presentation, diagnosis and pathogenesis of symptomatic sports-related femoroacetabular impingement (SRFAI) in a consecutive series of 1021 athletic hips. Hip Int. 2019;29(6):665-673.
  • Smolders JMH, Speirs AD, Frei H, Beaulé PE. Higher patient activity level and subchondral stiffening in asymptomatic cam femoroacetabular impingement subjects. J Hip Preserv Surg. 2018;5(3):259-266. Published 2018 Jun 22. doi:10.1093/ jhps/hny017
  • Zhou J, Melugin HP, Hale RF, Song BM, Okoroha KR, Levy BA, et al. Sex differences in the prevalence of radiographic findings of structural hip deformities in patients with symptomatic femoroacetabular impingement. Journal of hip preservation surgery. 2021;8(3):233-239.
  • Kang AC, Gooding AJ, Coates MH, Goh TD, Armour P, Rietveld J. Computed tomography assessment of hip joints in asymptomatic individuals in relation to femoroacetabular impingement. Am J Sports Med. 2010;38(6):1160-1165.
  • Aytekin, K. (2018). Türk Toplumunda Cam Tipi Femoro Asetabular İmpingiment (FAİ) Tanısında Kullanılan Radyolojik Değerlerin Asemptomatik Bireylerde İncelenmesi. Klinik Tıp Aile Hekimliği, 10 (3), 14-17. Retrieved from https://dergipark. org.tr/tr/pub/ktah/issue/47193/593368. 26. Hack K, Di Primio G, Rakhra K, Beaulé PE. Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am. 2010;92(14):2436-2444.
  • Gosvig KK, Jacobsen S, Sonne-Holm S, Gebuhr P. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the Copenhagen Osteoarthritis Study. Acta Radiol. 2008;49(4):436-441.
  • Leunig M, Jüni P, Werlen S, et al. Prevalence of cam and pincer-type deformities on hip MRI in an asymptomatic young Swiss female population: a cross-sectional study. Osteoarthritis Cartilage. 2013;21(4):544-550.
  • Chakraverty JK, Sullivan C, Gan C, Narayanaswamy S, Kamath S. Cam and pincer femoroacetabular impingement: CT findings of features resembling femoroacetabular impingement in a young population without symptoms. AJR Am J Roentgenol. 2013;200(2):389-395.
  • Lepage-Saucier M, Thiéry C, Larbi A, Lecouvet FE, Vande Berg BC, Omoumi P. Femoroacetabular impingement: normal values of the quantitative morphometric parameters in asymptomatic hips. European radiology. 2014;24(7):1707-1714.
  • Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Joint Surg Am. 2010;92(5):1162-1169.
  • Ochoa LM, Dawson L, Patzkowski JC, Hsu JR. Radiographic prevalence of femoroacetabular impingement in a young population with hip complaints is high. Clin Orthop Relat Res. 2010;468(10):2710-2714.
  • Pollard TC, Villar RN, Norton MR, et al. Genetic influences in the aetiology of femoroacetabular impingement: a sibling study. J Bone Joint Surg Br. 2010;92(2):209-216.
  • Erdem Sultanoğlu T., Ataoğlu S., Altınsoy H. B., Sultanoğlu H. Femoroasetabular sıkışma sendromlu hastalarda pelvik bölgenin radyolojik anormallikleri ve klinik sonuçlar. Mersin Univ Saglık Bilim Derg. 2021; 14(2): 282-290.
  • Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am. 2011;93 Suppl 2:17-21.
  • Leunig M, Beck M, Dora C, Ganz R. Femoroazetabuläres Impingement als Auslöser der Koxarthrose. Der Orthopäde. 2006; 35:77-84.
  • Pun S, Kumar D, Lane NE. Femoroacetabular impingement. Arthritis & rheumatology (Hoboken, NJ). 2015;67(1):17-27.
  • Tepeli B ve ark. Femoroasetabular Sıkışma Sendromu.J PMR Sci 2016;19(3).
  • Pasculli RM, Callahan EA, Wu J, Edralin N, Berrigan WA. Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome. Current reviews in musculoskeletal medicine. 2023;16(11):501-513.
  • Lin LJ, Akpinar B, Bloom DA, Youm T. Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups. 2021;49(1):82-89.
  • Hasegawa M, Morikawa M, Seaman M, Cheng VK, Sudo A. Population-based prevalence of femoroacetabular impingement in Japan. Mod Rheumatol. 2021;31(4):899-903.

Popülasyon Temelli: Femoroasetabular Impingement Değerlendirilmesi

Year 2024, Volume: 6 Issue: 2, 126 - 135, 30.06.2024
https://doi.org/10.52827/hititmedj.1339302

Abstract

Amaç: Femoroasetabular sıkışma, erken kalça osteoartriti oluşturma potansiyeli bulunan kalça ekleminin disfonksiyonudur. Bu çalışma ile herhangi bir endikasyonla pelvik Bilgisayarlı Tomografi incelemesi yapılmış olan hastaların Alfa Açısı ve Femur Boyun-Baş Offset ölçümlerinin radyoloji uzmanları ile birlikte incelenmesi amaçlandı.
Gereç ve Yöntem: 18-45 yaş arası çeşitli nedenlerle pelvik Bilgisayarlı Tomografi incelemesi (kontrastlı veya kontrastsız) yapılmış olan 891 bireyin sağ ve sol 1.782 kalça eklemine ait sonuçları retrospektif olarak değerlendirildi. Bilgisayarlı tomografi kesitlerinde Alfa Açısı ve Femur Boyun-Baş Offset ölçümleri yapıldı. Bu çalışmada, Alfa Açısının 55° ve üzerinde olması, Femur Boyun-Baş Offset mesafesinin 8 mm’den küçük olan ölçüm değerleri anormal olarak değerlendirildi.
Bulgular: Bu çalışmada 758’i (%85,1) erkek ve 133’ü (%14,9) kadın olmak üzere toplam 891 birey dahil edildi.
Bireylerin ortalama yaşı 24,65 ± 6,01 idi. Çalışmaya dahil edilen tüm bireylerin sağ Alfa Açısı ortalaması 45,42 ± 4,4 (min 38,00, maks 62,00), sol Alfa Açısı ortalaması 46,65 ± 5,1 (min 38,00, maks 72,10), sağ Femur Boyun-Baş Offset ortalaması 10,21±0,02 (min 6,2, maks 11,4), sol Femur Boyun-Baş Offset ortalaması 10,57 ± 0,01 (min 5,6, maks 12,0) idi. Her iki kalça ekleminde Alfa Açısı ≥ 55°bulunan birey sayısı toplam 37 olup bu bireylerin 33’ü erkek, 4’ü kadın idi. Her iki kalça ekleminde Femur Boyun-Baş Offset < 8 mm bulunan birey saptanmadı.
Sonuç: Femoroasetabular sıkışma ile ilişkili olduğu bilinen görüntüleme özellikleri özellikle erkek bireyler olmak üzere asemptomatik yetişkin kalça eklemlerinde görülmektedir. Asemptomatik genç erkek ve kadın bireylerde antropometrik ölçümlerin normal sınırlar dışında olması halinde bu bireylerin bulgularına yönelik klinik korelasyonu önerilmelidir.

Supporting Institution

Yok

Project Number

Yok

Thanks

Yok

References

  • Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage. J Bone Joint Surg Br. 2005;87-B(7):1012-1018.
  • Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):112-120.
  • Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris- Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644.
  • Fortier LM, Popovsky D, Durci MM, Norwood H, Sherman WF, Kaye AD. An Updated Review of Femoroacetabular Impingement Syndrome. Orthopedic reviews. 2022;14(3):37513.
  • Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008;466(2):264-272.
  • Wagner S, Hofstetter W, Chiquet M, et al. Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement. Osteoarthritis Cartilage. 2003;11(7):508-518.
  • Schmaranzer F, Kheterpal AB, Bredella MA. Best Practices: Hip Femoroacetabular Impingement. AJR Am J Roentgenol. 2021;216(3):585-598.
  • Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90 Suppl 4(Suppl 4):47-66.
  • Shaw C. Femoroacetabular Impingement Syndrome: A Cause of Hip Pain in Adolescents and Young Adults [published correction appears in Mo Med. 2017 Sep-Oct;114(5):352]. Mo Med. 2017;114(4):299-302.
  • Trigg SD, Schroeder JD, Hulsopple C. Femoroacetabular Impingement Syndrome. Curr Sports Med Rep. 2020;19(9):360- 366.
  • Kim J, Choi JA, Lee E, Lee KR. Prevalence of Imaging Features on CT Thought to Be Associated With Femoroacetabular Impingement: A Retrospective Analysis of 473 Asymptomatic Adult Hip Joints. AJR Am J Roentgenol. 2015;205(1): W100-W105.
  • Fernandez M, Wall P, O’Donnell J, Griffin D. Hip pain in young adults. Aust Fam Physician. 2014;43(4):205-209.
  • Murphy NJ, Eyles JP, Hunter DJ. Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in therapy. 2016;33(11):1921-1946.
  • Ahn T, Kim CH, Kim TH, Chang JS, Jeong MY, Aditya K, et al. What is the Prevalence of Radiographic Hip Findings Associated With Femoroacetabular Impingement in Asymptomatic Asian Volunteers? Clinical orthopaedics and related research. 2016;474(12):2655-2661.
  • Seijas, R., Pérez-Bellmunt, A., Barastegui, D. et al. Correction to: The natural history of alpha angle in the last seventeen centuries. Arch Orthop Trauma Surg 142, 2827 (2022).
  • Nötzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
  • Sutter R, Dietrich TJ, Zingg PO, Pfirrmann CW. How useful is the alpha angle for discriminating between symptomatic patients with cam-type femoroacetabular impingement and asymptomatic volunteers?. Radiology. 2012;264(2):514-521
  • Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
  • Wylie JD, Peters CL, Aoki SK. Natural History of Structural Hip Abnormalities and the Potential for Hip Preservation. The Journal of the American Academy of Orthopaedic Surgeons. 2018;26(15):515-525.
  • Amanatullah DF, Antkowiak T, Pillay K, Patel J, Refaat M, Toupadakis CA, et al. Femoroacetabular impingement: current concepts in diagnosis and treatment. Orthopedics. 2015;38(3):185-199.
  • Carton PF, Filan DJ. The clinical presentation, diagnosis and pathogenesis of symptomatic sports-related femoroacetabular impingement (SRFAI) in a consecutive series of 1021 athletic hips. Hip Int. 2019;29(6):665-673.
  • Smolders JMH, Speirs AD, Frei H, Beaulé PE. Higher patient activity level and subchondral stiffening in asymptomatic cam femoroacetabular impingement subjects. J Hip Preserv Surg. 2018;5(3):259-266. Published 2018 Jun 22. doi:10.1093/ jhps/hny017
  • Zhou J, Melugin HP, Hale RF, Song BM, Okoroha KR, Levy BA, et al. Sex differences in the prevalence of radiographic findings of structural hip deformities in patients with symptomatic femoroacetabular impingement. Journal of hip preservation surgery. 2021;8(3):233-239.
  • Kang AC, Gooding AJ, Coates MH, Goh TD, Armour P, Rietveld J. Computed tomography assessment of hip joints in asymptomatic individuals in relation to femoroacetabular impingement. Am J Sports Med. 2010;38(6):1160-1165.
  • Aytekin, K. (2018). Türk Toplumunda Cam Tipi Femoro Asetabular İmpingiment (FAİ) Tanısında Kullanılan Radyolojik Değerlerin Asemptomatik Bireylerde İncelenmesi. Klinik Tıp Aile Hekimliği, 10 (3), 14-17. Retrieved from https://dergipark. org.tr/tr/pub/ktah/issue/47193/593368. 26. Hack K, Di Primio G, Rakhra K, Beaulé PE. Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am. 2010;92(14):2436-2444.
  • Gosvig KK, Jacobsen S, Sonne-Holm S, Gebuhr P. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the Copenhagen Osteoarthritis Study. Acta Radiol. 2008;49(4):436-441.
  • Leunig M, Jüni P, Werlen S, et al. Prevalence of cam and pincer-type deformities on hip MRI in an asymptomatic young Swiss female population: a cross-sectional study. Osteoarthritis Cartilage. 2013;21(4):544-550.
  • Chakraverty JK, Sullivan C, Gan C, Narayanaswamy S, Kamath S. Cam and pincer femoroacetabular impingement: CT findings of features resembling femoroacetabular impingement in a young population without symptoms. AJR Am J Roentgenol. 2013;200(2):389-395.
  • Lepage-Saucier M, Thiéry C, Larbi A, Lecouvet FE, Vande Berg BC, Omoumi P. Femoroacetabular impingement: normal values of the quantitative morphometric parameters in asymptomatic hips. European radiology. 2014;24(7):1707-1714.
  • Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Joint Surg Am. 2010;92(5):1162-1169.
  • Ochoa LM, Dawson L, Patzkowski JC, Hsu JR. Radiographic prevalence of femoroacetabular impingement in a young population with hip complaints is high. Clin Orthop Relat Res. 2010;468(10):2710-2714.
  • Pollard TC, Villar RN, Norton MR, et al. Genetic influences in the aetiology of femoroacetabular impingement: a sibling study. J Bone Joint Surg Br. 2010;92(2):209-216.
  • Erdem Sultanoğlu T., Ataoğlu S., Altınsoy H. B., Sultanoğlu H. Femoroasetabular sıkışma sendromlu hastalarda pelvik bölgenin radyolojik anormallikleri ve klinik sonuçlar. Mersin Univ Saglık Bilim Derg. 2021; 14(2): 282-290.
  • Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am. 2011;93 Suppl 2:17-21.
  • Leunig M, Beck M, Dora C, Ganz R. Femoroazetabuläres Impingement als Auslöser der Koxarthrose. Der Orthopäde. 2006; 35:77-84.
  • Pun S, Kumar D, Lane NE. Femoroacetabular impingement. Arthritis & rheumatology (Hoboken, NJ). 2015;67(1):17-27.
  • Tepeli B ve ark. Femoroasetabular Sıkışma Sendromu.J PMR Sci 2016;19(3).
  • Pasculli RM, Callahan EA, Wu J, Edralin N, Berrigan WA. Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome. Current reviews in musculoskeletal medicine. 2023;16(11):501-513.
  • Lin LJ, Akpinar B, Bloom DA, Youm T. Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups. 2021;49(1):82-89.
  • Hasegawa M, Morikawa M, Seaman M, Cheng VK, Sudo A. Population-based prevalence of femoroacetabular impingement in Japan. Mod Rheumatol. 2021;31(4):899-903.
There are 40 citations in total.

Details

Primary Language Turkish
Subjects Clinical Sciences (Other)
Journal Section Research Articles
Authors

Nurgül Balcı 0000-0001-5950-3989

R. Pelin Kavak 0000-0001-9782-0029

Mesut Tıkman 0000-0003-1671-9661

Nezih Kavak 0000-0003-2751-0046

Senem Koca 0000-0003-2495-782X

Berna Turhan 0000-0003-2522-5719

Sümeyya Duran Kaymak 0000-0003-0593-1202

Project Number Yok
Publication Date June 30, 2024
Submission Date August 8, 2023
Acceptance Date March 20, 2024
Published in Issue Year 2024 Volume: 6 Issue: 2

Cite

AMA Balcı N, Kavak RP, Tıkman M, Kavak N, Koca S, Turhan B, Duran Kaymak S. Popülasyon Temelli: Femoroasetabular Impingement Değerlendirilmesi. Hitit Medical Journal. June 2024;6(2):126-135. doi:10.52827/hititmedj.1339302